Module 3 Unplanned Pregnancy and Abortion Care

Transcription

1 Module 3 Unplanned Pregnancy and Abortion Care

2 CSRH Module 3: Unplanned Pregnancy and Abortion Care Learning Outcomes: Develop a non-judgemental approach towards unplanned pregnancy and abortion care Have in depth knowledge of medical and surgical methods of abortion Provide holistic care for women requesting advice about unplanned pregnancy and abortion, including contraceptive, other sexual health and emotional needs. Have the knowledge, skills and attitude to lead or establish pregnancy testing and abortion service Develop an appreciation of the reasons that women have unplanned pregnancies, request abortion, including those with issues around domestic violence, drug and alcohol abuse, cultural issues and repeat termination Special consideration for Abortion Care: There may be conscientious objection to the acquisition of certain skills within this module. ALL trainees are expected to fulfil the clinical competencies, demonstrate the professional skills and attitudes and complete the log book competencies relating to Unplanned Pregnancy ALL trainees are expected to fulfil the clinical competencies, demonstrate the professional skills and attitudes and complete the log book competencies relating to Follow Up of women following abortion. ALL trainees are expected to meet the Knowledge Criteria throughout the module Trainees with conscientious objection to abortion are expected to demonstrate a non-judgemental attitude to women seeking abortion and make arrangement for them to receive timely and appropriate care from colleagues. Skills competencies not attempted because of conscientious objections should be clearly recorded in the logbook (using the letters CO and initialled by the trainee) and signed by the trainer

3 1. Unplanned pregnancy: Knowledge Criteria Clinical Competency Professional Skills and Attitudes Training Support Evidence/ Assessment The biochemistry and sensitivity of different pregnancy tests Attitudes to unplanned pregnancy abortion in different religious, ethnic and cultural groups Risk factors for unplanned pregnancy How to manage a community based, multiprovider, efficient, accessible and confidential pregnancy testing and support service networked to ongoing care by integrated care pathways Local pathways for antenatal care and adoption services for women who decide to continue their pregnancy Referral to and working of the local sexual assault referral centre (SARC) and supporting voluntary sector groups should the pregnancy be secondary to sexual assault If needed, perform a free, on-the-spot pregnancy test for women of all pregnancy choices: If pregnancy test is positive, discuss with the woman how she feels about the result of the pregnancy test and ask whether she wishes time to reflect or wishes referral for care. If the latter, discuss options of abortion, adoption or maternity care and if either of latter 2, enter into local adoption/ maternity care pathway and provide with advice re staying well in pregnancy. If abortion requested and personal conscientious objection, refer expeditiously to colleague willing to manage the woman If abortion requested and no personal conscientious objection, Take a clinical history indicating gestation, Assess for risk factors indicating the need for fast-tracking entry to other pathways of care or engagement of other members of the multidisciplinary team e.g. concurrent significant medical condition, safeguarding children, domestic violence, late gestation Physical health Mental health Sexual health Safeguarding children Vulnerable adult Domestic violence Disability Language/ cultural differences Identify distress, overtly and covertly displayed: support and offer specialist counselling as per local care pathway at every stage in the clinical episode Involve supporting partner/ carer/ friend appropriately Irrespective of personal beliefs, treat the woman with honesty and respect at all times Recognise high risk clinical situations and manage appropriately At every stage in the pathway, share discussion/decision making with the woman, if necessary using independent interpreting service/ providing whatever required to overcome any disability e.g. signing for the deaf Sensitively, accurately and nondirectively counsel about options available and associated health issues Respect right to confidentiality and know when this can be broken e.g. safeguarding children Discuss factors that might lead to the need to breach confidentiality Ascertain social support, encouraging parental / carer involvement where patient under 16 years old FSRH / RCOG Theory course in Abortion Care Counselling skills course Clinical observation by trainee of trainers Clinical training of trainee by trainers Self directed learning StratOG RCOG Clinical Guidance Documents: Abortion Recommended standards for sexual health services; MedFASH 2005 WHO Guidance Safe abortion: technical and policy guidance for health systems. WHO 2012 Clinical observation Logbooks: -clinical logbook -generic logbook -reflective diary -work-based tutorials -self-directed learning MSF / TO CBD Mini-CEX Log of cases

4 Knowledge Criteria Clinical Competency Professional Skills and Attitudes Training Support Evidence/ Assessment Perform a clinical assessment for gestation where necessary Assess for need of involvement of Safeguarding Children team Emergency referral to gynaecology department if clinical suspicion of ectopic pregnancy (pain, bleeding, history) Refer to central booking system of appropriate abortion carer as per local policy Provide written and verbal information on what to expect re appointments, therapeutic options, procedures Implement local policy for vulnerable adult if assessed as such Respect religious and culture diversity and beliefs Ensure woman/ carer knows who/ how to contact in an emergency (24 hour helpline availability) Discuss sexual health risk minimisation Discuss initiation and if possible supply post-procedure contraception /condoms for sexual safety Supply with contact details if any problems/ queries before next step in pathway Re-iterate the how to access counselling / support Document episode accurately

5 2. General Skills for Abortion care including pre-assessment and post-procedure review: Knowledge Criteria Clinical Competency Professional Skills and Attitudes Training Support Evidence/ Assessment Legal and ethical aspects of abortion Epidemiology of abortion global and local Medico legal aspects of abortion care: record keeping, information giving, consent, legal rights of partner/parent, sexual offences, local safeguarding children and vulnerable adult guidelines and policies and local forensic guidelines and policies. Development of the embryo and fetus Ultrasound appearances in early pregnancy including failed pregnancy, retained products of conception, ectopic pregnancy, molar pregnancy and correlation with HCG levels Pre-abortion investigations including routine blood tests, STI screening Knowledge of pharmacology of all drugs used at any stage in the abortion pathway Take a pre-abortion clinical history and perform risk assessment: 1. Physical 2. Psychological counselling / support needs 3. Social 4. Safeguarding children / vulnerable adult issues 5. Contraception 6. Sexually transmitted infection 7. Other significant medical conditions Perform appropriate clinical examination including full medical history and assessment of gestation Arrange routine laboratory and ultrasound investigations, and specific investigations as prompted by history and examination Arrange/ perform sexual health screen and arrange management and partner notification if positive Manage unexpected findings as per local care pathway e.g. miscarriage, ectopic gestation, molar pregnancy Explain clearly and openly treatment regimes, potential side effects of drugs and complications of procedures Arrange procedure locally or through another agency, including cervical priming and follow up as necessary, via care pathway Recognise high risk clinical situations and manage appropriately Identify distress, overtly and covertly displayed: support and offer specialist counselling as per local care pathway at every stage in clinical episode At every stage in the pathway, share discussion/decision making with the woman, if necessary using independent interpreting service/ providing whatever required to overcome any disability e.g. signer for the deaf Sensitively, accurately and nondirectively counsel about options available and associated health issues Discuss factors that might lead to the need to breach confidentiality Respect right to confidentiality and know when this can be broken e.g. safeguarding children Ascertain social support, encouraging parental / carer involvement where woman under 16 years old Assess for need of involvement of safeguarding Children team Implement local policy for vulnerable adult if assessed as such FSRH / RCOG Theory courses Counselling skills course Clinical observation by trainee of trainers Clinical training of trainee by trainers Self directed learning StratOG RCOG Clinical Guidance Documents: abortion, risk, fetal awareness and fetal abnormality Visit to a non-nhs service provider Visit to provider of any aspects of abortion care not provided in training unit Progress and priorities working together for high quality sexual health. Review of National Strategy for Sexual Health and HIV MedFASH 2008 Mandatory Specification for Pregnancy Services in the guidance on the NHS Clinical observation Logbooks: -clinical logbook -generic logbook -reflective diary -work-based tutorials -self-directed learning MSF / TO CBD Mini-CEX Log of cases

6 Knowledge Criteria Clinical Competency Professional Skills and Attitudes Training Support Evidence/ Assessment Medical and surgical methods of abortion at all gestations; methods and factors influencing choice of procedure (clinical and patient) Knowledge of factors leading to late and repeat abortion. Late medical abortion and feticide Issues surrounding fetal abnormality Sensitive disposal of fetal remains Management of fetal tissue following sexual assault Local control of substances Hazardous to Health policy Adverse sequelae of abortion and management of immediate and delayed complications Aftercare including care pathways to organisations for different aspects of ongoing care Knowledge of different service design, organisation and provision including local care Seek informed consent after assessment of competency; if not competent, implement local policy (adult or child) Supply appropriate information for women and their accompanying persons Prescribe drugs required for chosen procedure including cervical priming/ local antibiotic prophylaxis policy/ contraception as per local care pathway Arrange interpreter/signer if required Complete necessary documentation including HSA1 Post-procedure: Assess clinically: 1. Physical wellbeing 2. Psychological wellbeing; review counselling / support needs 3. Confirm procedure complete and review: 4. Social needs 5. Review safeguarding children / vulnerable adult issues 6. Contraceptive risk assessment 7. Sexually transmitted infection risk assessment Manage delayed complications including: - Bleeding - Infection - Retained products of conception - Ongoing pregnancy - Emotional distress Formulate and implement plan of management and modify it, if necessary Liase effectively with colleagues in other disciplines, clinical and nonclinical through Care Pathways Recognise the role and skills of the multidisciplinary team in the provision of comprehensive abortion services Respect religious and culture diversity and beliefs Check patient/ carer aware of procedure/ analgesia/ support Ensure patient/ carer knows who/ how to contact in an emergency (24 hour helpline availability) Discuss initiation of future chosen method of contraception Discuss sexual health risk minimisation See Appendix A for detailed Interview / History taking skills Standard Contract for Community Services 2010/2011

7 Knowledge Criteria Clinical Competency Professional Skills and Attitudes Training Support Evidence/ Assessment pathways for networking for NHS and in the private / charitable sector Discuss and arrange ongoing care through local networks and care pathways Knowledge of agencies providing support for women suffering domestic violence or who have been sexually assaulted Complete necessary documentation including HSA4 if appropriate Knowledge of recommended best commissioning practice Knowledge of Care Quality Commission criteria for abortion services.

8 3. Medical Abortion procedures: Knowledge Criteria Clinical Competency Professional Skills and Attitudes Training Support Evidence/ Assessment Organisation of medical abortion services including local care pathways for networking Medical abortion procedures including preand post procedure care at all gestations and place of feticide Medical abortion regimens, indications and contraindications, routes of administration of drugs, pharmacology of drugs including mifepristone and prostaglandins Possible complications and their management Aftercare including care pathways to organisations for different aspects of ongoing care At time of 1st visit for procedure: Check gestation Review suitability for procedure method. Double check no exclusion to drugs in regime Seek/ check consent, including unlicensed use of drugs Act appropriately on abnormal lab results Check all medication required for procedure is administered appropriately according to prescription/patient Group Direction Check future sexual health needs, including contraception, are discussed, prescribed and available Provide verbal and written advice about what bleeding, discomfort and drug side effects may be experienced and provide 24 hour contact numbers for information, advice and support. Ensure patient knows date time and place of next visit Complete all necessary documents including HSA1/4 if appropriate Identify distress, overtly and covertly displayed: support and offer specialist counselling as per local care pathway Discuss potential consequences of not completing treatment regime with patient Answer all questions asked openly and honestly Discuss expected pain and bleeding during/after procedure Identify need for follow up and arrange appropriately- e.g. for incomplete or non passage of POC, and potential issues of regret Recognise the role and skills of the multidisciplinary team in the provision of medical abortion services and their aftercare Theory course Clinical observation by trainee of trainers Clinical training of trainee by trainers Self directed learning Work based tutorials Clinical observation Logbooks: -clinical logbook -generic logbook -reflective diary -work-based tutorials -self-directed learning -audit of delayed complications MSF / TO CBD Mini-CEX OSATS Logbook of cases At time of 2 nd visit for procedure: Check all medication to be prescribed by doctor prescribed and available Administer prostaglandins If the abortion process is continued in the Unit i.e. patient does not go home to complete procedure: Manage pain/ nausea and any medication side effects to local protocol Manage abortion process Early gestations: Identify products of conception. Later gestations:

9 Knowledge Criteria Clinical Competency Professional Skills and Attitudes Training Support Evidence/ Assessment deliver fetus and placenta. Dispose of same with due regard to respect and dignity, and according to patient s wishes and cultural values (ascertain prior to procedure). Manage immediate complications (see Appendix 2 for further details) including the need for surgical evacuation of the uterus Prior to discharge (whether procedure completed in the Unit or at home): Confirm/ supply contraceptive provision/ condoms for sexual health and where to access further care e.g. intrauterine contraception/ supplies including LARC and permanent contraception Give written and verbal discharge instructions explaining what is normal and abnormal (signs and symptoms) in next few weeks Advise abstinence until bleeding stopped Reiterate who/ how to contact for help/ advice/ support Give anti D where clinically indicated Arrange follow up Complete necessary documentation

10 4. Surgical abortion procedures (up to 14 weeks) by manual or electric vacuum aspiration: Knowledge Criteria Clinical Competency Professional Skills and Attitudes Training Support Evidence/ Assessment Organisation of surgical abortion services including local care pathways for networking Surgical procedures including electrical and manual vacuum aspiration, local and general anaesthesia indications and contraindication including pre- and post-procedure care Possible complications and their management Aftercare including care pathways to organisations for different aspects of ongoing care At admission for procedure Check no change in health, consent or contraceptive choice if to be provided at this visit and manage if there is Check all drugs prescribed including priming, antibiotics and contraception Check equipment (including analgesia if not performed under GA) Clinical procedure: -Position patient -Bimanual examination (empty bladder) -Speculum examination -Stabilisation of cervix -Application of local anaesthetic if not under GA -Cervical dilatation, if required -Aspiration of uterine contents -Identification of products of conception and disposal of same with due regard to respect and dignity, and according to patient s wishes -Manage if inadequate products seen -Manage immediate complications (see Appendix 2 for details) Identify distress, overtly and covertly displayed: support and offer specialist counselling as per local care pathway Answer all questions asked openly and honestlydiscuss expected pain and bleeding during / after procedure Identify need for follow up and arrange appropriately- eg for suspected incomplete removal POC, and potential issues of regret Recognise the role and skills of the multidisciplinary team in the provision of comprehensive abortion services and their aftercare Theory course Work-based tutorials FSRH/RCOG Manual Vacuum evacuation course Clinical observation by trainee of trainers Clinical training of trainee by trainers Clinical observation Logbooks: -clinical logbook -generic logbook -reflective diary -work-based tutorials -self-directed learning -audit of delayed complications MSF / TO CBD Mini -CEX OSATS Logbook of cases Recovery and discharge Confirm/ supply contraceptive provision/ condoms for sexual health and where to access further care/ supplies Give written and verbal discharge instructions explaining what is normal and abnormal (signs and symptoms) in next few weeks Advise abstinence until bleeding stopped

11 Knowledge Criteria Clinical Competency Professional Skills and Attitudes Training Support Evidence/ Assessment Reiterate who/ how to contact for help/ advice/ support Arrange follow up Completion of necessary documentation including HSA 4

12 1. Unplanned pregnancy Skills Competency level: Basic training Intermediate training Advanced training Not required Level 1 Level 2 Level 3 Date Signature of trainer Date Signature of trainer Date Signature of trainer Perform a pregnancy test Discuss options honestly and in a non-directional manner if a positive pregnancy test Initiate antenatal / adoption care pathways Initiate abortion care pathways Assess and manage identified clinical and non-clinical risks Discuss and provide ongoing methods of contraception, or refer, as appropriate Perform and manage STI risk assessment Ensure closure of episode includes written and verbal information on ongoing care Demonstrate a non-judgemental and non-directive attitude to women with an unplanned pregnancy Effectively communicate with patients and accompanying persons, respecting diversity of beliefs Assess patient for competency as adult or child and if lacking competence, act according to local policy and guidelines Answer all questions openly and honestly

13 2. General Skills for Abortion care including pre-assessment and post-procedure review: Skills Competency level: Basic training Intermediate training Advanced training Not required Level 1 Level 2 Level 3 Date Signature of trainer Date Signature of trainer Date Signature of trainer Initial assessment of a woman seeking abortion: Take a history Undertake risk assessment and manage appropriately Perform a clinical examination Arrange appropriate investigations/sexual health screen Refer for specialist care, physical and/ or emotional Manage unexpected finding from routine assessment Effectively communicate with patients and accompanying persons, respecting diversity of beliefs Demonstrate a non-judgemental and non-directive attitude to women seeking abortion Answer all questions openly and honestly Assess patient for competency as adult or child and if so, act according to local policy and guidelines Check no safeguarding children issues and if so, act according to local policy and guidelines Effectively liaise and network with colleagues, including those in other departments(eg obstetrics, general medicine, primary care)

14 Discuss options with patient, involving partner/ supporter as she wishes Arrange procedure/ prescribe drugs Formulate, implement and, if necessary, modify management plans Completes documentation including consent Provide contraceptive and sexual health advice and supplies In the follow-up clinic: Perform a clinical assessment, physical and emotional Manage delayed complications Discuss and arrange ongoing care through the multidisciplinary team, including all sexual health needs and risk factors for repeat unplanned pregnancy Complete documentation if appropriate Effectively communicate with patients and accompanying persons, respecting diversity of beliefs Demonstrate a non-judgemental to women following abortion Answer all questions openly and honestly Formulate, implement and, if necessary, modify management plans

15 3. Medical Abortion: Skills Competency level: Basic training Intermediate training Advanced training Not required Level 1 Level 2 Level 3 Date Signature of trainer Date Signature of trainer Date Signature of trainer Perform pre-procedure checks (visit 1 and 2) Initiate the abortion (visit 1) Manage abortion, ensure expulsion of products if planned to occur in the Unit (visit 2) Complete documentation (visit 1 and 2) Manage immediate complications (Appendix 2) (visit 1 and 2) Supply written and verbal information on side effects and 24 hour contact information (visit 1 and 2) Provide contraceptive and sexual health advice and supplies and discharge information (visit 2) Monitor the procedure and communicate effectively with woman, partner/carer and clinical team Apply infection control principles and implement local disposal of human remains policy

16 4. Surgical abortion (up to 14 weeks) by manual or electric vacuum aspiration: Skills Competency level: Basic training Intermediate training Advanced training Not required Level 1 Level 2 Level 3 Date Signature of trainer Date Signature of trainer Date Signature of trainer Perform pre-op checks Perform MVA under LA analgesia Perform vacuum aspiration up to 14 weeks gestation under GA Manage immediate complications (Appendix 2) Provide post-op care Provide contraceptive and sexual health advice and supplies Communicate effectively with woman, partner/carer and clinical team throughout Complete documentation

17 Training courses or sessions Title Signature of Educational Supervisor Date Authorisation of signatures please print your name and sign Name (please print) Signature

18 Completion of Module 3: I confirm that all components of the module have been successfully completed. Date Name of Educational Supervisor Signature of Educational Supervisor

19 Appendix 1 to Module 3: Details of professional attitudes and skills criteria Interview/history taking skills: Respects and observes confidentiality Introduces self to client Involves others as appropriate e.g. interpreter, parent (with child s consent) Identifies client reason for consultation Allows client to elaborate, presenting problem fully Listens Puts client at ease Recognises client s verbal and non-verbal cues Uses silences appropriately Phrases questions simply and clearly Uses open questions, appropriate closed questions and focused questions (avoids double or misleading questions) Exhibits well organised approach to information gathering Seeks clarification of words used by client as appropriate Elicits specific and relevant information from client and/or their records to clarify management Check that any information given is understood If reads, writes notes or uses computer does so in a manner that does not interfere with dialogue and rapport Deals sensitively with embarrassing and/or disturbing topics Structures interview in logical sequence Display tact, empathy, respect and concern for the patient Respond effectively to any disclosure Non-judgemental and non-directive Display an understanding of how one s personal beliefs could affect the consultation Aware of and maintain the patient s dignity Aware of personal limitations Communicate appropriately and clearly, verbally and in writing, utilising (non-family) interpreters where appropriate Show appreciation and acceptance of the range of human sexuality, lifestyles and culture Recognise the importance of assessment of client with and without supporters- partner/parents Clinical Management: Formulates management plan appropriate to findings in collaboration with the client Gives explanations and information at appropriate times Checks clients level of knowledge and understanding Encourages client to discuss any additional points

20 Is prepared to use time appropriately Clinical Skills Checklist: Is sensitive to client physical and emotional discomfort Can identify ambivalence Can identify risk factors for subsequent regret Can arrange and carry out reviews Can identify the need for further counselling and support Refers appropriately Supports the patient and accompanying person Is capable of recognising limits of personal competence Problem Solving: Correctly interprets and applies information obtained from client Records history, physical examination and investigations Identifies problems or makes working diagnosis Behaviour/Relationship with Client/Other Staff checklist: Maintains friendly but professional relationship with client Demonstrates awareness that the client s attitude to the doctor (and vice versa) affects management and levels of co-operation Appendix 2 to Curriculum Module 3: Immediate complications of abortion procedures Surgical: Per-operative difficulties: dilatation, poor aspiration of uterine contents, blockage of cannula, haemorrhage, uterine atony, incomplete abortion, continuing pregnancy, vasovagal reaction, allergic reaction, uterine false passage/rupture, cervical laceration, air embolism, acute haematometra, Medical: Complications: adverse drug reaction, non-passage of POC, passage of POC between admissions, bleeding, atony, cervical shock, uterine rupture, ongoing pregnancy, nausea, vomiting and diarrhoea

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